CMAJ's Century Reflects a Profession and a Country

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CMAJ 100 Years

CMAJ’s century reflects a profession and a country

Charlotte Gray BA

he first decade of the 20th century was frenetic, with manned flights and Model T T cars in the United States and a naval armaments race in Europe. Medical and scientific knowledge was expanding at warp speed: Ivan Pavlov won the Nobel Prize for his research into digestion, Ernest Rutherford was exploring atomic structures and Paul Erhlich was develop- ing an effective drug for syphilis. And Canada? With a population of 5.3 million, the young country clung to British apron strings as it tottered toward sovereignty. Yet exhilaration swept this land too, and its growing professional class. Officers of the Canadian Medical Association, founded in Québec City, Quebec in the year of Confederation, 1867, shared the optimism. In 1911, the association took a bold step. To solidify its national and international ambitions, it established the monthly Canadian Medical Association Jour- 2663 N Collection, Foote Manitoba, of Archives At the time CMAJ began publishing, infant mortality rates were soaring to over nal, an amalgamation of the Montréal Medical 20 per cent, prompting government agencies to introduce public health educa- Journal and the Maritime Medical News. The tion programs. In this 1916 photo, a public health nurse in Winnipeg, Manitoba first issue promised to be “a medium for the uses a doll to show young women how to bathe a baby. expression of all that is best in Canadian medicine.” It was going to show the world that the country’s small cadre of some 7500 university- membership: the profession’s need for good sci- This is the first in a series of trained doctors deserved to be taken seriously. ence and a collective voice. CMAJ is a mirror of articles marking CMAJ’s 100th anniversary. From the start, the founding editor, Dr. (later both our doctors and our country. It is also a Sir) Andrew Macphail, Professor of the History periodical that has trodden a delicate line CMAJ 2011. DOI:10.1503 /cmaj.101799 of Medicine at McGill University in Montréal, between its role as house organ and the journal- set high standards for the journal and its contrib- istic impulse toward independence. utors. He championed professional autonomy. CMAJ was established at a propitious “The free play of the profession is impeded by moment in medical history: 1911 was probably unconsidered legislation.” And he wanted arti- the first year, medical historian Michael Bliss cles to be readable. “There is probably more bad reminds us, that “an ordinary person visiting a writing in medical journals than in any other doctor is said to have been more likely to be kind of periodical.” helped than harmed.” This was partly thanks to In the century that has passed since CMAJ’s medical advances, such as x-rays, and partly first issue (which consisted of 100 pages of because 1911 was also the year that there was dense print), the profession itself has grown in finally a legal requirement for physicians to strength (to more than 83 000 physicians) and apply for a licence to practise. Popular 19th- credibility. The society around it has evolved century nostrums like the widely advertised from a largely rural population with European “Dr. Williams’ Pink Pills for Pale People” roots to a multicultural, multilingual, urban began to lose their lustre. country with a population of 32 million and a In the journal’s first decade, when almost all gross domestic product that is the 11th largest in clinicians were generalists, public health issues the world. But for 100 years, the same issues quickly emerged as a priority. With life have preoccupied both the journal’s 16 subse- expectancy at only 52 years, and infant mortality quent editors and the CMA’s steadily growing rates of over 20 per cent, physicians faced a

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

100 Years

catalogue of communicable diseases — small- money expended in providing so-called working pox, polio, tuberculosis, cholera, syphilis and classes with better houses, on wider and better typhoid — for which they could offer few reme- lighted streets, would be more than recouped in a dies. Antibiotics and sophisticated technologies lessened expenditure in courts, prisons, asylums lay far in the future. and hospitals.” The CMAJ did, however, give an Macphail was a forceful character and a care- irresistible bully pulpit to some of its contributors ful reporter, whose articles had been published in who couldn’t keep a whiff of moral righteousness the Montreal Gazette and the Chicago Times. He out of their articles. In a 1911 piece entitled recognized that most of the prevalent diseases “Cocaine in Quebec,” the writer minimized the originated in contaminated water, poor nutrition, dangers of the common stimulant with the off- alcoholism and overcrowded slums. However, he hand comment that only “a few degenerate crea- left it to the CMA president to advocate public tures in the lower levels of city life employ it to policy. In the journal’s founding year, it was not alleviate their sense of misery.” the CMAJ’s editor but the CMA’s president who Events across the Atlantic were about to argued in the journal’s pages that the association unleash far more intense waves of misery. In Sep- should lobby “municipalities and the state that tember 1914, under the title “The War,” Macphail informed readers that within the 20 000-strong 1st Canadian Division assembling at Valcartier, Que- bec, was a medical corps of 50 physicians and 700 men. “It is a matter of congratulation that our profession is better prepared for the emergency than any other class in the community.” Within a few weeks, he too had secured an overseas post- ing, despite being over 50. For the next four years, CMAJ displayed its determination to be a useful resource for readers by carrying regular articles about skin grafts, treatment of nephritis and amputations, as well as poignant obituaries of association members killed in the line of duty. One of the most moving appeared in March 1918. It was almost certainly Macphail himself, a close friend of John McCrae, who described how “Jack” was beloved of patients and students. He noted sadly, “His name will live in poetry. The help to recruiting and to Victory Loans (public funding of the war effort) brought by his In Flanders Fields was enormous.” Another death, in 1919, was the occasion of a spe- cial memorial issue of the journal in January 1920. It honoured Sir William Osler, renowned as the father of modern medicine and universally acknowledged to be the most famous physician produced by Canada. Osler had also written a regular column, “Men and Books,” for CMAJ, which boosted the journal’s reputation and circulation. Following the war, doctors still grappled help- lessly with major health issues, with the influenza pandemic that had claimed 50 million lives around the world prompting a May 1920 article bemoaning the inadequacy of research on Bacil- lus influenzœ. However, the journal soon began publishing and celebrating the rapid advances of modern medicine in the first half of the 20th century. In 1922, Banting and Best (and colleagues) CMAJ wrote a “preliminary report” about their momen- In the yellowing pages of CMAJ’s first issue, tuberculosis was the “most impor- tant matter affecting the civilized world,” and the possible benefits of a new tous discovery of insulin, for which they received treatment for syphilis, “606,” were trumpeted. The complete inaugural issue is the Nobel Prize a year later. Canadian readers available on CMAJ’s 100th page at www.cmaj.ca. first learned about the use of living sutures in

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surgery, the first successful grafts of blood treatment of gunshot wounds to the brain and vessels and radium treatment for cancer in the anticoncussion bandeaux. Within a year, there journal’s columns. Dr. Wilder Penfield published was a whole section called “The War.” One-third on the physiology of the brain. Editors who filled of Canada’s physicians, some 3800, would even- Dr. Macphail’s shoes continued his scientific tually serve in the armed forces. CMAJ, still a rigour and his dry wit: in July 1937, a tongue-in- drab monthly publication with columns of small cheek “Ode to the Tonsils” was published. At the print, was more concerned with clinical medicine on the battlefield than with the economics of health care services at home. In 1942, a spe- “There is probably more cial bulletin was prepared for physicians serving bad writing in medical overseas. It had little impact, however: bundles of the publication were discovered at war’s end, journals than in any other neatly packaged in the CMA’s Toronto head- quarters. They had never reached Europe. kind of periodical.” The troops were barely out of uniform before the CMA, and provincial medical associations, same time, moral judgements continued to colour started work on health insurance proposals. The medical practice. In July 1930, under the title Beveridge Report in Britain, which established “Sterilization for human betterment,” one author the National Health Service, was fiercely debated urged wider use of sterilization to prevent births in Canada — nowhere more fiercely than in of “the weak, the degenerate and the generally CMAJ. However, as a January 1949 editorial unfit.” He deplored the fact that, “at one time, we pointed out, there were constitutional obstacles to bred from the top; now [thanks to medical such a universal system of health care on this side advances and charity] we breed from top and bot- of the Atlantic. The federal government had tom, and, indeed, rather more from the bottom.” already embarked on a system of provincial The dangerous implications of the eugenics grants, but “we have yet to make our weight felt movement would soon become horribly evident in the shaping of policy.” It was not going to be in Nazi Germany. easy for the national association to reach As the bruising Depression took hold in the consensus on national needs, when the initiatives 1930s, doctors began to worry about unpaid bills, and their concerns showed up in the Medical Eco- nomics and Correspondence columns. Discus- sions about government-sponsored health insurance began, with tension simmering between those who favoured government schemes and those who shared Macphail’s early resistance to “unconsidered legislation.” In March 1935, Dr. J. C. McMillan was the first of many writers to explore in print ideas to resolve the situation. Under the title, “A Proposed Scheme of Health Insurance for Manitoba,” he described how “the present depression has served to reveal many inherent weaknesses in our present system of supplying medical services.” He deplored the move in Saskatchewan to a system of 107 “municipal doctors,” salaried by the government, and instead calculated how a medical association might run its own insurance system, financed through provincial taxation. It was a harbinger not only of the great Canadian Medicare battle of the 1960s, but also of the future shift in focus for CMAJ. But first events in Europe once again directed Canadian attention overseas. In October 1939, the lead editorial was titled simply, “War,” and began ominously: “The die is cast. We are at PA-167232 / Canada Archives and Defence/Library National of Department Canada. / Stirton M. Alexander Capt. One-third of Canada’s physicians, some 3800, served in World War II. In this war. It is needless to review the situation and April 14, 1945 image, personnel in a field hygiene section of the Royal Cana- ask, ‘Why?’” Soon pages were filled with arti- dian Army Medical Corps, delouse liberated Russian prisoners-of-war in cles about medical examinations of recruits, Friesoythe, Germany.

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were all taken at provincial level. CMAJ main- the ad boom, the majority of pages continued to tained a scrupulously balanced tone in its com- be filled with scientific and medicosocial arti- ments, while association officers watched med- cles. Editorial staff worked hard to persuade top- ical clout shifting toward provincial associations. level Canadian scientific investigators and edu- From this point onward, the CMA was preoc- cators to write for CMAJ, rather than for journals cupied by the politicization of health care, but its like The Lancet, The New England Journal of leverage within Ottawa relied on the credibility Medicine or the British Medical Journal. and muscle of its members rather than any for- Major changes were also afoot outside the mal relationship. CMAJ, still primarily a scien- journal. By the 1960s, it was evident that a tific publication, made sure that doctors were national public health care system was going to be kept informed about political discussions. And introduced into Canada, administered provincially all along, the journal’s literary pretensions and funded from both federal and provincial remained. The September 1954 issue featured a taxes. During most of the feverish debates, CMA verse entitled, “My amoeba is unaware” by the leaders rather than CMAJ editors articulated famous Montréal lawyer and poet F.R. Scott, physicians’ positions. Significant comments on which included the line, “Truly a marvel of the 1962 Saskatchewan doctors’ strike appeared adaptation, equally at home in ponds or in the presidential address of Dr. W.W. Wigle, paunches, since the beginning of life.” published in the journal. In a direct echo of the In the second half of the 20th century, Canada founding editor’s concerns, Wigle warned about “the dangers and ominous presence of political In 1955, the journal began publishing expediency.” But from the sidelines, editors offered a different view. An unsigned editorial in twice a month, which meant more August 1962 denounced the “demagogues” who indulged in “violent criticism, much of which is space for science and commerce. formless, blind and unreasoning” and which con- tributed to the “hate-the-doctor phenomenon.” once again plunged into a period of dramatic The Medical Care Act finally passed in 1966, change. Suburbs sprawled across farmlands; and with the advent of medicare, physician num- cranes hovered over new steel-and-cement bers and income grew over the next three schoolhouses; ordinary families could finally decades. The CMA found itself navigating afford cars, holidays and an avalanche of labour- through difficult issues like abortion, drug abuse, saving domestic appliances. Increased affluence contraception, confidentiality and genetic coun- showed up in CMAJ articles about several new selling. This was the Mad Men era in which drugs for psychiatric conditions, a new section advertising equated cigarettes with masculinity devoted to medical films and concern about some and independence, and a proposed ban on smok- innovations. A correspondent in February 1955 ing in hospitals proved controversial. Individual argued that there were far too many television doctors struggled with increasingly complex tax- programs with medical themes, pandering to ation and regulation. Through the 1970s, CMAJ, “unwholesome seekers after vicarious thrills.” now located in the same building in Ottawa as the What would the writer have made of today’s orgy CMA, strove to stay ahead of doctors’ concerns. of medical dramas, such as House and Grey’s The journal provided information on cutting-edge Anatomy? In step with political concerns outside genetic research, retirement savings plans and the the profession, CMAJ began giving its title in use of computers in the office. It became a much French as well as English in 1959, and including more attractive publication, with a modular abstracts and the occasional article in French. design, full-colour covers and glossy paper. Up until then, advertisements had been con- But medical publication was now a crowded fined discreetly to the back of the book, but in market. Should CMAJ continue to try to uphold 1955 the journal began publishing twice a Macphail’s original dictum, “a medium for the month, which meant more space for both science expression of all that is best in Canadian medicine,” and commerce: the number of pages occupied by or should it concede some ground to specialty jour- pharmaceutical company advertisers continued nals and focus on supplying information and over- to mushroom. In 1948, the association reported sight articles for a wider general audience? revenue from CMAJ of $88 552: by 1958, it had By the end of the 20th century, CMAJ had jumped to $399 214. Cresting the wave of phar- opted for the latter course. Peer-reviewed scien- maceutical advertising, the journal went weekly tific material remained the centrepiece, but there in 1967 and immediately began losing money; was an expanded letters section and more 29 months later it lost its postal subsidy and emphasis on public health and articles useful for reverted to twice monthly publication. Despite a general practitioner. Back numbers from these

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years read like comfortable national conversa- tions between colleagues. Its seminal series on evidence-based medicine continues to be exten- sively cited. Successive editors strove to provide often off-beat and provocative material in a news and features section that might catch a busy doctor’s attention. There were also forays into the new discipline of medical humanities, including narrative medicine articles and critiques of contemporary art works. A poem entitled “Oh, I was there, too (Swissair flight 111, Peggy’s Cove, September 1998),” by Shane Neilson, a clinical clerk, which opened with the chilling line, “Among the things that startle / are a set of lungs / perfectly removed from a body,” was published in August 1999. The spirit of Dr. John McRae MD Williams David Today, high technology and evidence have transformed medicine. Medical continued to hover over the journal. researchers at the NASA Extreme Environment Mission Operation (NEEMO) However, as CMAJ edged into less traditional are experimenting with robotic surgery underwater — conditions that mimic areas and became more professional and sophisti- those in space. cated, its role as the CMA’s house organ grew increasingly unstable. The tension built under Dr. founding editor, including a commitment to pro- John Hoey, who became editor in 1996 and liked viding practical information to physicians. to challenge readers — and the CMA — with But the journal is also hugely different with its editorials on controversial issues such as decrimi- international focus, contemporary, full-colour nalization of marijuana. In November 2005, mat- design, expanded news focus and influential edi- ters came to a head over a draft news article torials. Recently, the journal has deplored the about behind-the-counter access to emergency Harper government’s cancellation of the long- levonorgestrel. Citing concerns that readers might form census, demanded early release of the H1N1 mistake the article for research, the CMA execu- vaccine and urged caution in pursuing a radical tive insisted that certain sections be deleted. The new treatment of multiple sclerosis. Macphail article was revised, and shortly after Hoey pub- would surely have applauded the crisp writing and lished an editorial objecting to “interference in passion embodied in these statements. editorial decisions.” Within a few months, Hoey This first decade of the 21st century in Canada and a senior editor were dismissed, and several is the age of “there’s-an-app-for-that” medicine. other editors resigned. CMAJ found itself the sub- The average lifespan for Canadians is now 81 ject of unflattering media attention. Following on years and infant mortality is at 5.0 per 1000 live an external review headed by Montréal lawyer births. However, even though much has changed Dick Pound, the arm’s-length relationship since January 1911, Macphail’s original dictum between journal and association was clarified, that CMAJ be “a medium for the expression of all with a strengthened oversight committee. that is best in Canadian medicine” still stands, Meanwhile, the Internet revolution was rock- even if the same thing is said with fewer words in ing the world of media globally. Under Hoey 2011: “Medical knowledge that matters.” and Dr. Paul Hébert, who became the journal’s 17th editor in 2006, the emphasis on online Charlotte Gray, an award-winning historian and offerings increased, with the website becoming biographer, was a regular contributor to CMAJ for the “journal of record” in 2004. Today, far more a decade. Her recently published eighth book is Gold material appears online at www.cmaj.ca than in Diggers, Striking It Rich in the Klondike. She is a the 18 print issues published annually. Despite member of the Order of Canada and a Fellow of the the changing emphasis, Hébert remains loyal to Royal Society of Canada. the paper version. “Every time we do reader sur- veys, we hear that people like the print journal.” Although medicine, the profession and the More CMAJ anniversary articles available at www.cmaj.ca country itself in 2011 would be unrecognizable • MacDermot HE. The fiftieth anniversary of the association journal. to Sir Andrew Macphail, he would likely recog- CMAJ 1961;84:1–5. nize the tone of scientific enquiry and profes- • Gray C. CMAJ: 75 years as the voice of the profession. CMAJ 1986: sional civility that still characterizes CMAJ. As 135:1405–8. the journal enters its second century, its editorial • Wooltorton E. CMAJ, 90 years ago. CMAJ 2001;165:1631–4. team has many of the same preoccupations as the

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